Raymona Stevens: The Case

HPI:

Raymona Stevens is a 65-year-old new patient to your family medicine residency clinic practice who is changing doctors due to the retirement of her former physician. She reports on her clinic intake form that she has been treated for diabetes since 2010, and that her medication is metformin 1500 mg three times a day. Her last doctor retired over 6 months ago; it took her awhile to get into a new primary care doc. She thinks the last labs she had drawn were over a year ago.

When you ask more about how she manages her diabetes and what lifestyle changes she has made, she reports that she only eats “white stuff” (bread, potatoes, rice) 2 times a day and fried foods once or twice a week at the advice of her former doctor, and that she knows she needs to exercise more but has been having pains in her lower right leg with walking, which had been her main form of exercise. She doesn’t check her blood sugar or use a glucometer because “no one told me I needed to.”

When you ask about her leg pain, she says that when she walks more than a block or so, it feels like she has a “charley horse” in her right calf and she has to stop walking until the pain goes away.

Additional history on the intake form shows:

Past Medical History:

Pregnancy at age 23 and 25, both resulting in live births

Hysterectomy at age 45 due to endometriosis

Family History:

Mother died from a “heart attack” at age 61

Mother had diabetes

Father died from colon cancer at age 70

Medications and Allergies:

No drug allergies

Metformin 1500mg TID

Ibuprofen 100mg BID as needed for pain

Smokes about 1 pack of cigarettes a week, has cut down from ½ pack a day formerly

Lives with her husband of 41 years, who is her emergency contact.

Physical Exam:

Blood Pressure 150/95 Pulse 87 RR 16 Wt 226 lbs Ht 5’ 7”

General Appearance: Overweight female, well groomed

HEENT: EOMI, moist mucous membranes, no thyromegaly

CV: RRR, no murmurs

Resp: clear bilaterally

Abd: Soft, non-tender, unable to appreciate liver or spleen due to habitus

You discuss the main goals of this visit and advise Mrs. Stevens that a new set of baseline labs are needed with close follow-up in the next week to address findings. In addition, you explain that her blood pressure is high and will need follow-up and action after the next office visit as well. You refer her to a nutritionist to discuss optimal dietary changes, and ask her to hold off on exercise until you can get more test results back. You also explain that you need to refer her to an ophthalmologist for an exam and recommendations. Finally, you tell her she needs special testing to look for problems with blood flow that could be causing the pain in her right calf.

She is skeptical because she has been feeling OK and will have to take additional time off work for these visits and work-up, but reluctantly agrees to get the tests done and see you in the following week.

She has the ordered diagnostic tests performed and they return:

Hba1c: 9.8%

Fasting blood sugar: 163

Post-Prandial Blood sugar: 298

Creatinine: 1.3

Spot urine albumin to creatinine ratio 45 ug/mg

Total cholesterol 210, LDL 120, HDL 36, Triglycerides 241

Right ankle-brachial index (ABI): 0.52

Left ankle-brachial index (ABI): 0.9

Mrs. Stevens has a 9 am appointment with you the following day. What course of management will you propose?